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Infections During Pregnancy

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Genital Herpes Simplex  (HSV-2)

Genital herpes is a sexually transmitted disease (STD) usually caused by  the herpes simplex virus- 2. The virus  infects epithelial cells,  and then travels up peripheral nerves to neurons where it may stay for years followed by reactivation. The incubation period is 2 to 12 days.

Electron micrograph at right reveals the presence of numerous icosahedral herpes simplex virions, members of the Herpesviridae virus family. At the core of its capsid, the HSV contains a double-stranded DNA linear genome.

Primary maternal infection may present as a flu-like syndrome with fever, headache, malaise, and myalgias. Many individuals with HSV-2 may never have sores or have only very mild symptoms. However, grouped painful, superficial genital blisters and ulcers on or around the genitals or rectum are typical in symptomatic patients. Viral culture of the ulcers is the preferred test to diagnose the infection.
Public Health Image Library (PHIL)
Dr. Fred Murphy; Sylvia Whitfield

Primary infection may be treated with oral antivirals [7]:

    Acyclovir 400 mg orally TID for 7 to 10 days    OR
    Valacyclovir 1 gram orally BID for 7 to 10 days

Severe or disseminated infections may be treated with acyclovir intravenously:

    5 to 10 mg/kg  intravenously every 8 hours for 2 to 7 days, then oral therapy to complete a 10 day course.

The American American Congress of Obstetricians and Gynecologists. (ACOG)  recommends that women with active recurrent genital herpes should be offered suppressive viral therapy from 36 weeks until delivery [7]:

    Valacyclovir 500 mg orally BID   OR
    Acyclovir 400 mg orally tid

Transplacental infection of the fetus is rare during pregnancy. Intrauterine HSV infection has uncommonly been associated with skin lesions, chorioretinitis, microcephaly, hydranencephaly , and microphthalmia [1,2]. While primary HSV infections in the first trimester are associated with higher rates of spontaneous abortion and stillbirth [3]. infection later in pregnancy appears more likely to be associated with preterm labor or growth restriction[4].

Of greatest concern is the risk of primary infection acquired at birth which could lead to herpetic meningitis.  The infection rate is 34 to 80% for infants born vaginally during a  primary infection. The risk falls to 1 to 5% for infants born vaginally during a recurrent infection [4, 5,6].

Cesarean section is recommended for all women in labor with active genital lesions or  prodromal symptoms such as vulvar pain.

For patients with preterm premature rupture of membranes remote from term complicated by recurrent maternal HSV infection, the risks of prematurity should be weighed against the risk of neonatal HSV disease in considering expectant management.  Prophylactic treatment with antiviral agents (eg, acyclovir) may be considered if expectant management is chosen [6-8].

 

REFERENCES:
1. Shepard TH. Catalog of Teratogenic Agents pp 1323. 9th ed.Baltimore, MD: Johns Hopkins University Press, 1998
2. Hutto C, Arvin A, Jacobs R, Steele R, Stagno S, Lyrene R, Willett L, Powell D, Andersen R, Werthammer J, et al. Intrauterine herpes simplex virus infections. J Pediatr. 110:97-101, 1987 PubMed
3. Freij BJ, Sever JL: Herpesvirus infections in pregnancy: Risks to embryo, fetus, and neonate. Clin Perinatol 15:203-231, 1988
4. Brown ZA, Vontver LA, Benedetti J, et al: Effects on infants of a first episode of genital herpes during pregnancy. N Engl J Med 312:1246, 1987
5. Stagno S, Whitley RJ: Herpesvirus infections of pregnancy. Part II: Herpes simplex, virus and varicella zoster infections. N Engl J Med 313:1327-1330, 1985 PubMed
6.ACOG Practice Bulletin No. 80: premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists
Obstet Gynecol 2007
7. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. No. 82 June 2007. Management of herpes in pregnancy. Obstet Gynecol 2007

  • Major CA, Towers CV, Lewis DF, Garite TJ. Expectant management of preterm premature rupture of membranes complicated by active recurrent genital herpes. Am J Obstet Gynecol 2003 188(6):1551-4 PMID: 12824992  

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